The “Top-Five” Ways to Improve Primary Care (and Reduce Costs…)

When we dole out blame for rising health care costs the familiar suspects are hospitals, insurers, and profit-hungry drug and device makers. High-priced specialists usually rate a mention as well. But what about primary care physicians? It turns out that through excessive testing, improper prescribing and other types of unnecessary care these “gate-keepers” also contribute to spiraling health care spending. And worse, this excess treatment not only doesn’t help patients, it can actually harm them.

This week the National Physician’s Alliance released the "Top 5" ways primary care physicians like internists, family practitioners and pediatricians can reduce health care costs while also improving the quality of care for their patients. Their recommendations are surprisingly simple and in most cases advise against the overuse of certain tests and therapies. They are recommendations that should be—but often aren’t—considered the standard of care; for example, not ordering EKG’s or cardiac screening for low-risk patients; not prescribing antibiotics for a child’s sore throat until a strep test confirms infection, and not performing x-rays or CT scans on patients who have experienced fewer than six weeks of lower back pain unless “red flags” are present.

The National Physician’s Alliance (NPA) is a doctor’s group with 22,000 members that does not accept money from drug companies and works to “ensure affordable, high-quality health care for all.”  The “Top 5” lists were originally compiled by the NPA’s Good Stewardship Working Group, which included subgroups of doctors from three fields of primary care — family medicine, internal medicine and pediatrics. Each was asked to come up with five ways to reduce costs in their areas while also improving patient care. These recommendations were then “field-tested” by 255 other doctors to come up with the final “Top 5” lists that were published in an article earlier this week in the on-line edition of Archives of Internal Medicine. (For those without access, I’ve included the three lists of recommendations at the end of this post.)

On the blog SF Gate published by the San Francisco Chronicle, Ricky Y. Choi, a pediatrician who serves on the board of directors of NPA writes that primary care doctors need to face up to the fact that whether intentionally or not, they are contributing to the seemingly unstoppable rise in health care spending:

“Every physician that I know makes medical decisions with the patient's best interest in mind. But conscious or not, there are competing influences. Patients may demand a particular medication they heard about from a friend or TV commercial. A drug representative may suggest the physician prescribe their drug over a cheaper medication that works just as well. A provider may order a few extra tests not because it is supported by evidence but out of fear of being sued. A procedure may be performed more often than medically indicated because it brings revenue to the practice.

“The overwhelming direction is toward more care and higher costs. As much as 30% of all health care spending is estimated to go to unnecessary care. The other problem in this situation (and in a lot of others I can think of) is that more is not always better. In fact, more care can cause harm. The overuse of antibiotics have contributed to the rise in drug resistant bacteria that now make even simple infections harder to treat. The repetitive use of x-rays and CTs increase the risk of cancer particularly in children. Painful testing and potentially harmful procedures are often performed even when the results will not change the condition's management.

Choi asks; “So what should health care providers do differently?”

In the Archives paper, the stewardship group calls for better communication between doctors and patients; “For example, many primary care physicians state that pressure from patients leads them to prescribe antibiotics when they are not indicated. Yet studies have shown that, in fact, patients don’t expect antibiotics nearly as often as doctors believe they do.”

The NPA is planning on developing training videos around their “Top 5” lists and using other tools to help doctors relay to patients that they are making treatment decisions based on strong evidence and standard practice. The Archives authors hope that this improved communication can “help dispel the misconception that these clinical recommendations represent rationing and support the idea that often less is truly more.”

Here, then, are the lists:

Top 5 Internal Medicine

    * Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.

    * Screening: Don’t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in healthy adults who don’t have symptoms.

    * EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.

    * Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.

    * Bone Density: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

Top 5 Pediatrics

    * Throat Infections: Don’t prescribe antibiotics for pharyngitis (sore throat) unless the patient tests positive for streptococcus (Strep throat). [According to an article in Time, “Most cases of sore throat are viral, yet antibiotics are prescribed more than half the time, contributing to drug resistance and high costs.”

    * Head Injuries: Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors [The risks of radiation exposure for kids far outweigh any benefits of scanning otherwise]

    * Fluid in the Middle Ear: Don’t refer otitis media with effusion early in the course of the problem. [Again, most ear infections are viral and will go away on their own without antibiotics.]

    * Cold Medications: Advise patients not to use cough and cold medications. [Recent studies have shown that these medications have no benefit and parents often use incorrect dosages, leading to harmful side-effects.]

    * Asthma: Use inhaled corticosteroids (a steroid medication) to control asthma appropriately.

Top 5 Family Medicine

    * Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.

    * Sinusitis: Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis (inflammation of the sinuses) unless symptoms – which must include purulent (full of pus) nasal secretions AND maxillary (upper jaw bone) pain or facial or dental tenderness to percussion – last for 7 days OR symptoms worsen after initial clinical improvement. [The Time piece notes; “Despite the fact that most sinusitis is caused by a viral infection, antibiotics are still prescribed in more than 80% of outpatient cases. That adds up: each year sinusitis results in 16 million office visits and $5.8 billion in costs, even though viral infections will clear on their own.”]

    * EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.

    * Pap smears: Don’t perform Pap tests on patients younger than 21 years or in women have had a hysterectomy for benign disease.

    * Bone scans: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

5 thoughts on “The “Top-Five” Ways to Improve Primary Care (and Reduce Costs…)

  1. I practice by these guidelines, but, honestly, this is such small change. An entire career of practicing this way doesn’t amount to one year of a mid-level health exec’s salary, or one unwarranted bariatric procedure with complications. Let’s follow Willy Sutton’s advice, and attack where the money is.

  2. That’s great, blame the victim. These problems are the result of a system that has progressively devalued primary care and left PCPs without the time or energy to deliver the type of care that they dreamed about when they went to med school. This is like telling a man dying in the desert that he wouldn’t be so dehydrated if he would just drink more water.

  3. Applause, Dr. Rick.
    I love your two questions, but until we change how we reimburse it’ll never happen. Those two questions open up cans of worms busy office docs don’t want to handle because they don’t get paid to.

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